Friday, March 20, 2009

The King of Cringe Strikes Again

As I've written on this blog before, Dr. Joseph Biederman is an outstanding scientist but is also the prototypical MGH/Harvard narcissist. I speak from experience, having attended the MGH psychiatry residency from 1992-1995. We all joked about our arrogance and hubris and narcissism. It was almost a badge of honor. When you are at the top-ranked psychiatry department in the nation (as MGH has been every single year from 1995 to 2008, according to U.S. News and World Report) you are entitled to an extra heaping of, umm, positive self-regard, shall we say.

So Biederman's seemingly outrageous comments, as reported in today's New York Times, have to be taken into context.

Here are the comments:

In a contentious Feb. 26 deposition between Dr. Biederman and lawyers for the states, he was asked what rank he held at Harvard. “Full professor,” he answered.“What’s after that?” asked a lawyer, Fletch Trammell.“God,” Dr. Biederman responded.“Did you say God?” Mr. Trammell asked.“Yeah,” Dr. Biederman said.

If you've tasted MGH culture, you'd find this comment very funny. Biederman was not really saying that he was just below God; instead, he was cracking a joke about academic hierarchy at Harvard, presumably to break the tension at the deposition.

The more damning documents are those implying that Biederman promised Johnson & Johnson officials positive data about their products. I haven't reviewed the published studies in question, but knowing the quality of Biederman's research, I suspect that it is well-done and above board. He may have already seen some preliminary data showing advantages of Risperdal over Zyprexa in pediatric bipolar disorder, or showing that Concerta was unlikely to retard growth. I'd be extremely surprised if he manipulated these studies in some fraudulant way to create the results he promised. That's not the way Biederman rolls.

Call him the King of Cringe. Disagree with his opinions about the prevalence of pediatric bipolar disorder. Call him greedy, even. But scientifically, I continue to respect him and I believe that he ultimately has the best interests of his patients at heart.

60 comments:

Marilyn Mann
said...

Danny,

I disagree with you on every single point you made in your post. I'm sorry.

I have zero respect for Biederman and in fact consider him an arrogant SOB. I do not trust his results. Whether he consciously manipulated his experimental design to achieve a specific result I do not know, but that is not a necessary element to produce a biased result.

If this is the pinnacle of academic excellence in psychiatry it is a sorry state of affairs indeed.

I'm confused by your post. In general your opinions in posts are backed up by data. In this case you admit to not seeing the data, and yet are expressing fairly strong support for the person. This seems inconsistent to me.

I am sorry too because I generally respect your work greatly, Danny, but calling Biederman an "outstanding scientist" is stretching it a lot I would say. Maybe back in the early nineties he had some redeeming qualities as a scientist but becoming a KOL and getting wined and dined by an industry that is focused on next quarter's earnings rather than the welfare of any patient worked its insidious influence on any ethical judgment he may have possessed. It's easy to understand how this slippery slope works and how the ego gets inflated more and more as the substance of achievement actually gets less and less. The poor patent gets lost in the shuffle and when we're talking about children the outrage against the perpetrators is well deserved.

He probably regrets the "God" comment, but having been in these depositions, I know it is easy to blurt something out under pressure. I am sure the product liability attorney deposing him was pretty vicious. As for Dan's comment, it isn't always easy seeing someone you know or trained with get creamed...

Medinformatics: I just read your pages. Amazing! I'm glad they finally got busted. How about another one in Yale General Counsel office having a "hypothetical" conversation on the train with someone from the Office of Research Integrity relating to another physician who recently left Yale and (frivolous) accusations made by other narcisstic faculty there. Someone said they are like a bunch of Indian chiefs all counting how many feathers there are in each other's headdresses. I think we need a post just on the topic of narcissistic academics.

Listen, I am a patient and was treated by one of Biederman's narcissistic colleagues at MGH. I was misdiagnosed with Bipolar disorder 9 years ago and fed a diet of risperdal and depakote.

(This particular staff member was and is a paid consultant to Janssen, as well as being on their speaker's bureau, and has received "honoraria" from them.

At best, the man was shallow and lacked any capacity for self-reflection. I will be soon having my bone density measured to see how all that risperdal affected their maturation.

My point is, these people are nuts. I would bet 80% of their patients my age have a similar story, or some story, with the common thread being they were misdiagnosed with bipolar disease and it had a devastating effects in their life trajectory.

This guy is well-respected and has a faculty appointment at Harvard, yet he is so unthoughtful and shallow.

Having felt the effects of Biederman's awesome science first-hand. I thought I might add a human face to the topic, figuratively speaking.

BTW, Biederman is a physician, not a scientist. Continually re-emphasizing that his "science" is sound and that he is a great "scien"tist is a diversionary tactic designed to insulate from everyone's mind the fact that the very point in question, because of newly available evidence, is that his science isn't sound.

And Carlat, your whole blog is about unsavory conflicts of interest in medicine. Unsavory is putting it lightly. But you totally bat a blind eye to Biederman. No, 1.2 million, undisclosed dollars has had no effect on his research.

I understand you trained there during their glory days, but God, your bland denial is painfully obvious.

Did you read the Globe today? Testimony that would be "immensely damaging personally AND professionally" doesn't sound to me like the testimony of a great "scientist".

Well, you can continue your bland, shallow defenses and I'll be another statistic, a great kid in a bad set of circumstances who was seriously mistreated by the best psychiatry department in the nation and you'll sleep soundly, not ever wondering if you were wrong, if my wasted life counts more or less than the hundreds or others, or if one life wasted is the same as all the rest.

PS Dr. Carlat, please post this. I didn't curse once and no one was personally attacked. I may have said things that are unfair, but I tried to be as civil as possible. I didn't even use the clinician's name who treated me. Please post it, I beg of you.

I just do not understand why you defend people like this, sir. Living in a town that has an arrogant institution like how MGH is viewed by the other programs in Boston, I have little tolerance to read others defend a program just because it produces allegedly fine physicians. Yes, some are, as I sense you fit that determination, but come on, this guy!?

At the end of the day, it is deeds, not words that define us. And, my interpretation of the "God" comment is not hilarity, but dismissive to the investigator at the disposition. Remember, as it was in our recert exam last year, "what personality disorder uses denial, displacement, and projection as defenses: the antisocial", but to me equally, the narcissist.

Dr.C: With all due respect to your high brow training at Harvard, did you ever once attend classes regarding projection and indirect methods of personality assessment? You know. Maybe a class on the TAT or Rorschach? Methods where ambiguous stimuli or situations that are presented to a client, and what flows from their brow might be considered to be significant aspects of their world view or ways that they perceive themselves or others? I mean, you invoked your experiences at Harvard as an apology for Biederman’s God comment. Surely in your training at Harvard, you must have run across Henry Murray, M.D. TAT’s work at the Harvard Psychological Clinic in this regard??? So Biederman faces an ambiguous situation in the format of a deposition hearing and, in the process, compares himself to God? And you do not think his bombastic statement is clinically significant as to the Good Doctor’s view of himself?? Sorry. You will not have the guts to publish this comment: But you are as delusional as Biederman. I expected much more of you.

Not everyone is totally evil, not everyone is totally good. Speaking as someone who was excoriated for blogging about someone I worked with who was attacked for conflict of interest issues, I can identify with Dr. Carlat. This is life. We all try to aspire to be the best that we can be (sorry to adapt the military advertisement). Give him a break. His morals and ethics are, in my opinion, inscrutible. Don't blame him for the people he trained with. We have a new generation now and things will change.

Well said, Doug. I think we should stop attacking Danny for painting a more nuanced picture of Biederman. Who knows what he was really like 15+ years ago for one thing? A lot can happen to a man in that time.

Doug gets my vote for the Voice of Wisdom. Perhaps the "new generation" you refer will blow out to sea some of the same, tired, pedantic opinions which go round-n-round this debate and offer nothing positive or progressive. Cheers, j

this blog - and the Biederman post - is about conflict-of-interest. And yet we're talking about an ill-advised, off-the-cuff, narcissistic comment - and about arrogance at Harvard?

it underscores the two levels of discussion going on here. There's a real problem with conflict of interest in our field - and many of us are glad to see it being sorted out, if saddened to see good people like Biederman (who has devoted his career to trying to help really, really sick kids) dragged through the mud.

BUT - and here's my concern - this is also about the 'I don't trust psychiatrists, I don't trust medications, I don't trust doctors, I don't trust Harvard' crowd. It's this second anti-intellectual, Scientologist line of argument that scares me.

Let's talk about conflict of interest, and leave the other stuff to the 50 other antipsychiatry blogs out there.

Coincidence or irony, the March 2009 issue of Psychatric Annals (PsychiatricAnnalsonline.com) is devoted to Narcissitic Personality Disorders (Part 1, 'cause this is too big a subject for one issue, figuratively and literally!).

I offer to the less psychiatric aware readers this summary by Otto Kernberg, the guest editor here, who is well known for his work with borderline P D/O, I feel is so on the mark for the key players in these disgusting revelations to psychiatry's sliming:

per 2. Pathology of the relationship with others: These patients[the narcissist] suffer from inordinate envy, both conscious and unconscious. They show greediness and explotation of others, entitlement, devaluation of others, and an incapacity to depend on them (in contrast with ongoing need for admiration from others). They show a remarkable lack of empathy with others, shallowness in their emotional life, and a lack of capacity for committment to relationships or goals.

I would add a caveat to the end there, 'or strive in a committment to a goal that is seen as enshrining them to the public/society for eons'.

Kernberg spends most of the editorial talking of the struggles to work with these folks in therapy, and believe me when I say from experience as a family member and a professional in dealing with those with this disorder, there is so little room for negotiation or acceptance, I do not think they are worth the time to help UNLESS they spontaneously say they are looking for it(help) for themselves at the beginning of the relationship.

You know, when you read this outside the connotation as just a patient, applies to basically a good portion of people in political hierarchy in place more than 12 years, as is it the source for the adage "power corrupts, and absolute power corrupts absolutely." When enough people suck up to you and your word is received as near gospel, it tarnishes even the best of initial intentions.

Just watch how Obama will turn, if he already hasn't.

Audacity of Hope? He has the audacity to use this term and message to sell himself!!!

Just an opinon, sorry I went off topic here at the end, but it applies overall.

Memphis was quite the show yesterday, eh? March Madness it is!

PS: Dr Carlat, do you pick the word verification words? This one for me was 'BERATERS'.

Localdoc's perceptive and concise advice punctuates the core contributions that this blog can make: To expose the "real problem with conflict of interest in [psychiatry]," and NOT the "anti-intellectual, Scientologist line of argument" which is represented by numerous antipsychiatry blogs.

Ironically, as if to unscore localdoc's point, the next post illustrates the dangers of a little knowledge, and takes this thread on a rambling journey ending with a blanket condemnation of both Dr. Biederman and President Obama as suffering Narcissitic Personality Disorder.

While the blogosphere is admirable for its lack of censorship, the caliber of readership and authority which any given blog may or may not enjoy directly mirrors the caliber of contributions to the blog. Opinions will always vary widly. Nevertheless, localdoc's suggestion that staying on point is critical to the effectiveness of The Carlat Psychiatry Blog is sage advice and comes not a moment too soon.

I wonder what Salvador Minuchin would say here. In the biz these types are referred to as “rogue investigators.” Universities that shelter rogue investigators regularly frustrate those responsible for promoting integrity in research.

Bernard Schwetz, who retired as Director of OHRP in 2007, said, “If we can influence a community to behave ethically, the science can take care of itself.”

According to various news reports, Biederman’s attorneys attempted to have the judge quash the release of the deposition transcripts; they apparently tried to protect Biederman from “embarrassment” about the disclosure of his “promised” results to the drug companies BEFORE any research was conducted. I don’t believe that Dr. Carlat’s rationalization that Biederman probably had preliminary data and he was simply giving the drug companies a preview is credible, in light of Biederman's attorneys’ efforts on his behalf. Oh, and to localdoc: Few on this board, I think, question Dr. Carlat’s morals and ethics. He does fine work for us in this field and is a force in helping to reform psychiatry. And most commenters are not anti-psychiaty or anti-medication. I am certainly not. But as to whether Biederman's research is above "mud"-- well, there are certainly legitimate questions in that regard. Hence his bid to suppress his deposition. What did he have to hide????

Thank you, Dr. Carlat, Dr. Bremner, and James for a bit of internet-based sanity on this topic. And thanks, localdoc, for saying what I've said from the beginning, because it was so obvious:

"BUT - and here's my concern - this is also about the 'I don't trust psychiatrists, I don't trust medications, I don't trust doctors, I don't trust Harvard' crowd. It's this second anti-intellectual, Scientologist line of argument that scares me."

It's no surprise that cognitive dissonance still reigns with the pitchfork crowd. They'd rather selfishly stew in their prejudices (or their own misfiring neurons) than admit Dr. Biederman has helped more people than they could ever imagine. And their certainty about this flows more plentifully than compassion or logic.

Conflict of interest is a problem, but not for them. They simply refuse to accept that children can have bi-polar disorder or that children who take medication are anything but powerless victims. Talk about low insight and projection. Talk about the patient getting lost in the shuffle.

Why on earth would anyone be shocked that the people who make their way to the top are often narcissistic? Who else wants/needs it so badly ?

Moreover, if you accept the premise of Simon Baron-Cohen's systems-empathy polarity and you accept that narcissism typically has its roots in low empathy (empathy being a function of the brain), you can understand why the people who score high at both ends are rare indeed.

We sure expect a lot of people these days. And the vigilantes have never been so empowered.

"this is also about the 'I don't trust psychiatrists, I don't trust medications, I don't trust doctors, I don't trust Harvard' crowd. It's this second anti-intellectual, Scientologist line of argument that scares me."

With all due respect, this seems a little off the mark. Labeling criticism of Biederman as "an anti-intellectual, Scientologist line of argument" is just not justified or productive.

Q. And do you agree that you are one of the most forceful advocates of the aggressive treatment of preschoolers?

A.(Biederman)It is her statement about me.

Q.I didn't ask you if it was her statement about you.I'm asking you if you agree that you are one of the most forceful advocates of the aggressive treatment of preschoolers.

A.(Biederman) I am.

You can read on where he admits there are no long term studies on Risperdal in children or adults; but that doesn't matter! Biederman says even without the science he will continue to prescribe this drug in his practice to preschoolers.

How about the six breaches of protocol in his study that were never reported?

I guess that is called sound science in psychiatry today?

I just love when those of us out in the real world beyond those holier than thou walls at Harvard question the ethics and science behind those like Biederman.

We are called and labeled the anti-psychiatry crowd or even placed in Scientology's slot.

Yeah, you call those people outrageous! Yet, so many of those mighty Dr.'s are circling the wagons in defence of the undefendable.

Who's got the real problem here?

Doctors as supposed reasonable professionals would call this a change for the good and making progress?

This is the status as normal in medicine as it stands today; when the doctor is wrong, don't ever blame the doctor; instead blame the patient and critics.

By not answering some pretty simple questions here Dr Carlat; you have in view of many answered them quite clearly by not taking a stand.

I believe this kind of narcissism has got the anti-psychiatry grass roots patient movement in full swing and making great strides toward marginalizing and debunking the very profession and industry many here so ardently defend even in the worst examples of conduct as in the your renowned Biederman.

Maybe you have forgotten that real people just as valued as your selves and family members are harmed by this kind of reckless medicine every day; many times beyond repair by the likes of this greed mongering and self appointed god complex in absolute thinking behaviour.

You just keep on making light of the aggregious acts of these industry opinion leaders and institutions.

To those non-club members at Harvard and the medical inside crowd: it appears that we have a profession here that is playing apologist, by their own rules, and doesn't see the train coming speeding down the tracks; headed right at your coveted profession.

I'm thankful that Senator Grassley doesn't read this situation like so many on the inside of the bubble do!

Maybe the narcissistic comment hit a little too close to home for some people. Not directed to you, sir, but there is a fine line between narcissism and antisocial traits, and maybe that is a topic that could have some applicability to this specific post, Re what Mr Bierderman could be about?

Sometimes people can have a level of narcissism that does them more good than harm, but can lose that boundary if praise and money is heaped onto such an individual too quickly.

By the way, Mr LaRossa, in an earlier post in your reply about transparency, you mention the hope to see meds work quickly in depression, to end dementia (if I recall the comments accurately). Yeah, I would like to see cancer be eradicated, and heart disease be ended. I also want peace on earth and all to never go hungry.

Careful what you wish for, sir. It is this drive to feel you could cure the world that can blind you to possibly cursing it instead.

You want transparency from me? I have been practicing psychiatry between community mental health and private practice settings for 15 years now, and what I see in colleagues and from patients as a near majority now is the curse.

Biochemical imbalance as the focus? Right! I'm sure it will save all those marriages, jobs, bank accounts, homes, dysfunctional families, and the endless barrage of this medium about not just our culture, but the world.

The ride is too fast, sir. People need to slow down and appreciate the scenery, sometimes maybe get off and get the feet on the ground.

I became a psychiatrist to have meds as one option to treatment, not the only option. Didn't really read your comment to be that transparent, but maybe I missed something. That does happen sometimes.

One last point, if I may, politicians are a reflection of the public that votes them into office. So, if we have insensitive, egotistical, selfish representatives, maybe that reflects what people are looking for in representation. And, to run the risk of extrapolating that to the point of this blog, what is the public to assume in learning of these alleged leaders being so greedy and dismissive of legitimate concerns and NOT read the average MD sounding concerned or alarmed? Guilty by association.

Disclaimer: I am not a Scientologist, and feel an arguement dismissing people with questions regarding ethics and integrity of science, and outcome for drug approval a result--- makes a person appear arrogant and not willing to change or see things except from own perspective, why not be open-minded and keep the conversation flowing for all parties to gain from?)

I would offer this discussion these questions:

1) Why did Harvard/MGH not inform the NIH about Dr. Biederman’s collaboration with J&J when it applied for the NIH bipolar disorder grant?

2) Several documents that Dr. Biederman supplied to the court make note of a “JB rent fund.” What is the “JB rent fund” and to whom did the money go?

3) Why did MGH not inform OHRP about the IRB protocol violations in Dr. Biederman’s study?

4) For that particular study, please explain each IRB protocol violation and how those violations were resolved.

5) Did representatives of MGH discuss collaborating on the Center with marketing people from J&J, as Attachment H states?

6) Were the slides detailed in the attachments to this letter created by Dr. Biederman? If not, who created them?

7) Please explain if these slides were ever presented to an audience. If so, who saw these presentations?

The questions are from Senator Grassley, re: the breach of Protocol in Joseph Biederman's trial of antipsychotics on preschool age children.

Asking this from an interested stance here, as a mother of a child harmed by psych meds. I didn't choose to want to think about the questions I ask. I question a lot now, as a result of my daughter being disabled from the drugs. Most regular readers of this blog know her story, so I don't need to say any more.

Has anyone else read the deposition from Feb 27, 2009 that I left the link for above?

Stan wrote:You can read on where he admits there are no long term studies on Risperdal in children or adults; but that doesn't matter! Biederman says even without the science he will continue to prescribe this drug in his practice to preschoolers.

-------

There are KNOWN risks -- often fatal ones-- to NOT treating these children, too.

therapyfirst wrote:Biochemical imbalance as the focus? Right! I'm sure it will save all those marriages, jobs, bank accounts, homes, dysfunctional families, and the endless barrage of this medium about not just our culture, but the world.

------If more psychiatrists learned how to judiciously use these medications, yes, it would go a long way towards saving marriages, jobs, etc.

Have you bothered to learn how medication can increase empathy, by the way? You were so skeptical a few months ago. If your prime interest were patient well-being, I imagine you'd have investigated this. A little knowledge goes a long way.

This is moving along fast and furiously, so please allow a a brief clarification. To Marilyn Mann, who quotes from Gina Pera and condemns the comparison of Biederman to Scientology and the like. Please note that Gina was quoting localdoc, who had made the original reference. Both localdoc and Gina, each with insightful comments, seem to be in agreement with you, which may have been confused by the quotation's third incarnation. I believe that all three of you are in agreement that this "line of argument is just not justified or productive."

Thanks to Doug Bremner for beginning the process of bringing us all back down to Earth and to Nancy and Stephany for keeping things fresh and on point.

Lastly, unless the President or his representatives say or do something which impacts this thread, it is degrading to us all to imply that he is somehow representative of a collective conscious that is "insensitive, egotistical, [and] selfish." This is not even remotely applicable to this debate.

Hmmm, again people are quick to defend that psychotropics have a sizeable place in health care, yet do not take the risk of making a statement of fair transparency to show it is a fairly unbiased, objective position.

So, I'll take some responsibility and start by stating for the record I have absolutely no tie in with any company or organization that profits from health care interventions, and state my position without any ulterior motive other than I reject the meds first paradigm that increasingly rules psychiatry like a metatstatic cancer.

As I said at Clin Psych, my rhetoric is going to get tougher when I read others are still looking the other way. I may be banned if I go too far, and if that is the assessment, then so be it.

I do not trust you, Mr LaRossa, and if I am incorrect in that assessment, your commentary will speak the volumes to redirect me.

No more politician analogies, but hey, consistency is the hallmark of success, and what you do in the assorted venues of your life speak volumes for who you are.

I hope others will weigh in with more insights and appraisals. This is fun!!

therapyfirst, board recert MD; Licensed in my home state since Nov of 1990, board cert since 1997

As an addendum, go read Leonard Pitts column in today's (March 23) Miami Herald, www.miamiherald.com, and think about this absurd adage, if the majority is thinking or doing it, it must be right. Because that is how some seem to come across here, at this site.

63% of people polled will not miss newspapers as a medium folding. Gee, with some of the revelations about these "exemplary KOLs" coming from ink print, you have to wonder why the news media is seen as so yesterday.

As Pitts notes so well, the criminals won't miss the newspapers. Can't wait to read whatever dissention this comment creates. Will be revealing until proven otherwise.

catch the replies Tuesday, I think I am done for today. The last med check did me in with this "better living through chemistry" expectation. "Therapy takes too long, I want to feel better NOW!"

Narcissism, greed, godliness, arrogance......It is difficult enough to watch the moneychangers on Wall Street display these qualities. Is it too much to expect that a physician, a healer, will not have these traits?Finally, is it possible that you are not being objective in your appraisal of a mentor inside the hallowed halls of MGH- seems like one might be in a trance?

The point of the post was to say that there are some things Biederman is guilty of, and some things he isn't. Narcissism, egotism, greed? Yep. Fraud, perpetrator of evil, creator of pediatric bipolar disorder, impetus for all psychiatrists who have ever prescribed too many antipsychotics? Of course not. This is not Dr. Mengele. And anyone who wants to go to pubmed and read his clinical trials will actually find that they are, for the most part very well done and written up fairly without exaggerating positive findings or downplaying side effects. Bipolar disorder does, in fact, occur in children, whether you call in bipolar or conduct disorder or juvenile delinquency. And it is clear that antipsychotics moderate the behavior, though at the cost of significant side effects. Welcome to medicine, a world where there are no perfect solutions to many challenging problems.

It's time to stop blaming Biederman for all of psychiatry's failings and for all of the evils of the pharmaceutical industry. Let's put our energies into something more productive--like coming up with solutions for how to appropriately work with industry without doing their marketing for them.

It's nice to see Gina Pera and her ilk making a grand re-appearance on this blog. Root out the Scientologists! Lynch the ignorant, mis-firing neuronal, anti-psychiatry, anti-medication crowd! Joe Biederman for President! He saves children and all you ignorant, non Harvard-trained idiots need to appreciate the role of anti-psychotic medications for children! Fine. But what do you have to say about one of the premier psychiatric researchers in the world, Nancy Andreasen's, M.D. comments, given in a September 18, 2008 interview to the NY TIMES? I submit the following for your review:Q. TODAY, IMAGING STUDIES ARE ONE OF THE MAINSTAYS OF NEUROSCIENCE. WHEN DID ATTITUDES CHANGE?A. In the early 1980s, when magnetic resonance imaging came on line. M.R.I.’s did not expose patients to radiation, and you could see brain structures in exquisite detail. I decided to use it for a longitudinal study of brain changes over a long period of time. We’re asking: Is schizophrenia a neurodegenerative disease like Alzheimer’s?In 1989, I began to collect subjects — some with schizophrenia and some not — and began taking pictures of their brains. With the schizophrenics, we began seeing them at the first onset of their disease, which is usually at around age 24. We recruited about 538 people with schizophrenia. Eighteen years later, we’re still following 305. Q. AND WHAT HAVE YOU FOUND?A. I haven’t published this yet. But I have spoken about it in public lectures. The big finding is that people with schizophrenia are losing brain tissue at a more rapid rate than healthy people of comparable age. Some are losing as much as 1 percent per year. That’s an awful lot over an 18-year period. And then we’re trying to figure out why. Another thing we’ve discovered is that the more drugs you’ve been given, the more brain tissue you lose.Q. WHY DO YOU THINK THIS IS HAPPENING?A. Well, what exactly do these drugs do? They block basal ganglia activity. The prefrontal cortex doesn’t get the input it needs and is being shut down by drugs. That reduces the psychotic symptoms. It also causes the prefrontal cortex to slowly atrophy.If I were developing new drugs, I’d switch targets. Till now it’s been chemically formulated targets. I believe we should be thinking more anatomically and asking, “With schizophrenics, which brain regions are functioning abnormally?”Q. ARE YOU WORRIED YOUR FINDINGS MIGHT BE MISUSED?A. The reason I sat on these findings for a couple of years was that I just wanted to be absolutely sure it was true. My biggest fear is that people who need the drugs will stop taking them. Q. WHAT ARE THE POLICY IMPLICATIONS OF THIS FINDING?A. Implication 1: that these drugs have to be used at the lowest possible dose, which often doesn’t happen now. There’s huge economic pressure to medicate patients very rapidly and to get them out of the hospital right away. Implication 2: we need to find other drugs that work on other systems and parts of the brain. Implication 3: whatever medications we use need to be combined with more nonmedication-oriented treatments, like cognitive or social therapies. OK, there you have it, folks! Do you want your children on anti-psychotic meds for "pediatric bipolar" disorder??? YOU decide. Me? No way.

I guess it takes a while to shake off the MGH (Massive Genitals Hospital :-) ) sheen.

Your following statement is very perplexing:"Bipolar disorder does, in fact, occur in children, whether you call in bipolar or conduct disorder or juvenile delinquency"

- No, bipolar disorder is not a moniker for conduct disorder or juvenile delinquency. It is a mood disorder, with the hallmark of a manic episode as a central requirement for a dagnosis. It does sometimes occur in children, but not in the same scale as claimed by Biederman and colleagues, who have used the diagnosis to willnilly recommend powerful "not-so-innocuous" atypical antipsychotics on a variety of non-bipolar children. If the condition is truly bipolar disorder, it is very suspicious why Biederman and colleagues have kept pushing the expensive "under patent" atypical antipsychotics when there are multiple cheaper and more effective mood stabilizers available, which are the first line of treatment for bipolar disorder anyway, and whose side effects are much less severe than the atypical antipsychotics

While your attempts to defend and protect a former MGH colleague is admirable, you have lost significant credibility in our eyes with this blatant and irrational defense.

"The point of the post was to say that there are some things Biederman is guilty of, and some things he isn't. Narcissism, egotism, greed? Yep. Fraud, perpetrator of evil, creator of pediatric bipolar disorder, impetus for all psychiatrists who have ever prescribed too many antipsychotics? Of course not. This is not Dr. Mengele . . . It's time to stop blaming Biederman for all of psychiatry's failings and for all of the evils of the pharmaceutical industry."

Danny,

Which one of us said that Dr. Biederman was equivalent to Dr. Mengele or that he was solely responsible for the overprescribing of antipsychotics in children? Which one of us said Biederman was solely responsible for psychiatry's failings or for all the evils of the pharmaceutical industry? No one that I know of. Certainly, I never said that. It is one thing to state your own opinion, which you are certainly entitled to. But please do not misrepresent the arguments of people who disagree with you.

1. To Mr LaRossa, I can mention Obama at this site since the blog author brought politics into this site by endorsing him last year. And, I believe analogies and metaphors have their place in debates like this. You don't agree, fine, but don't insult me like you did in the earlier post. And, I don't want an apology, I want transparency. Do you or do you not have any relations as of now to organizations or companies that profit from health care? It is a simple question, and even if you do does not infer you are wrong, but put your cards out on the table, sir.

2. Blind faith in leadership is exactly that, a loss of your senses. Just because someone was once a responsible leader or KOL does not mean they don't lose that standing. I know of a doctor in the area I work who was a great guy and physician, and when he took the hit from insurers in the early 90's and then became a pharma whore with his alleged clinicial trials in his private practice, he is now the shill many of my respected colleagues see him to be. So, I don't care what Biederman USED to be, what is he now?

3. In transition to that last commment, I read Steven Moffic's piece in the March 2009 Clinical Psychiatry News (www.clinicalpsychiatrynews.com) and found this statement at the bottom third of the piece very illuminating: "managed care organizations promised appropriate referrals to well selected clinicians, but most often this has turned out to be a case of referring to those who would accept the lowest fees." My point in repeating this statement: would psychiatrists these days shill for drugs if they could still practice psychotherapy for a sizeable part of their practices? I believe not, and people I respect who are trying to maintain therapy as part of their clinical travels seem to relate the growing dissapointment in losing this intervention. And, offense intended to those who take it, too many people who are not trained to provide therapy have only enabled and empowered insurers to insist on using these "providers" for such services.

4. (and last) Same journal, different piece, Paul Fink writes about treating narcissism and starts off with this: "A recent study of psychiatric outpatients showed a link between failure to complete treatment and narcissim. ...The study, published online in the Journal of Psychiatric Research, describes how difficult it is to treat patients with narcissistic character disorder. I agree."Forget treating these people, just try working with them. I take Biederman's comments as flagrant narcissism, and to dismiss or rationalize his ego as 'part of the territory' does a great disservice to those who know humility and embrace a multifaceted model to treatment.

To Dr Carlat, this man may be no Mengele, but I find it interesting you use this analogy when I have been called to task for using Nazi analogies here in the past. Read last week's Time magazine and there is a brief piece about Madoff where Elie Wiesel calls Madoff evil. The man wiped out Wiesel's organization, and guess what, you don't have to kill people to be evil, because as Bram Stoker wrote in Dracula, there are worse things than death.

Encouraging quick medicating of youth and potentially damning them to illnesses like obesity, diabetes, heart disease, and yet to know neurological problems bathing a developing brain in big time psychotropics may turn out to show, certainly can fit that description of worse things than death.

You may have worked with him, but, do you really KNOW him? If you do, then an opinion of experience. The readers like me are calling you on basically defending this guy, not your saying just "we don't have all the facts yet", which we don't.

I sense Biederman was a wonderful teacher. Exactly the problem really because what he was teaching from my own real world experiences was hogwash. This is how Jennifer Bremer describes it on her blog: "Dr. Biederman would scold us if we were not aggressive in our treatment of children. He would question our hesitance. Dr Biederman would ask why we would want to wait until the child grew sicker before treating him adequately? Why not treat now? He encouraged us to think about the risks of not treating a child, as well as the risks of treating. And, if we talked about the patient's psychotherapy for a diagnosis where there was not data -- he would refer to the therapy as 'tushy massage.' Research should guide treatment. His humorous comments drove home the point. Dr. Biederman handed out reprints by the handful, emphasizing the role of research for clinical care."

And just where was the research about the toxicity and long term effects of the remedies he was so aggressively pushing, especially on children -- on their physical and sexual development for one thing? Where was the proof that the children really were going to get sicker if there were no medications administered or better if they were? And what familial or environmental situation was it that was causing these kids to be sick in the first place? These illnesses really do not come out of the blue. What was Biederman recommending about the stressors that created the situation? I'm still saying the "science" Biederman was citing wasn't really applicable in clinical practice -- 8-12 week trials on a handful of kids in many cases. What do they really demonstrate that can help a troubled family? They may not be badly designed in and of themselves, but what do they prove that has lasting value in the real world given the chemical dependency and withdrawal issues that the treatments lead to after that time period? I don't think Biederman was deliberately misleading his students but I sure think his whole line of thinking was seriously flawed.

Boy: If Dr. Andreasen's research is accurate regarding the dose-dependent relationship between anti-psychotic medication and brain volume loss, just think of how much brain damage we can inflict by aggressive early intervention with children! Why, by the time these children are adults, we won't have to worry about treatment any longer -- they will be brain dead! Go get 'em, Joe!!!

Sara,In case you are unfamiliar with the kinds of cases seen by people like Biederman, they have usually involved visits with all kinds of behaviorists, psychodynamic therapists, and run-of-the-mill psychiatrists before ever getting to that point.

They try for years, and the situation only gets worse. You want to scar a kid for life? Let a behaviorist attempt to treat his/her brain disorder. Therapists who can't discern a treatable-with-therapy situation from a brain condition should come with their own black-box warning.

Thank you for agreeing, even if it is few and far between. I do appreciate the feedback.

I am taking 10 days off, as per a post at Psych Central noted about 3 weeks ago, to rejuvenate and regroup. I will end with this though, to be provocative and thought provoking, if these two adjectives are separate descriptors. I think a lot of the regulars here have an obligation to be transparent and direct, so I hope people will maintain this attitude and perspective in future comments and discussions. I think some commenters are full of crap, and if you won't come clean, then I hope you end up soiling yourselves completely. And, if I am wrong, then I stand corrected I assumed erroneously.

But, read Furious Seasons today and learn how atypicals are the number 1 money making drug class for 2008, and then explain to us, the naive readers and doctors, how this makes sense in this culture where somatic illnesses should still be a tad more prevalent than psychosis and mood disorders. That statistic should bother any MD with a healthy conscience.

I would bet there will be defenders quick to justify these numbers, and all I ask, is what is your agenda as a defender to defend it. If you profit from these meds, I have little respect for you, expecially if you are a provider. What a conflict of interest!!!

Have a nice 10 days, hope there will be interesting posts to follow up on in April.

Gina,It could be true that some of the patients that Dr. Biederman was seeing were as sick as you describe, who got there after failing many other avenues. However, to extrapolate from these rare cases and recommend the "run-of-the-mill" psychiatrists (as you put it) that they should prescribe antipsychotics to hordes of children is not proper.

Using your analogy, psychiatrists that can so precisely discern bipolar disorder when all the "run-of-the-mill" psychiatrists have failed, should come with their own green($$$)-box warning.

Ms. Gina Pera: With all DUE respect, behavioral therapy causes scaring and brain damage??? Really: What planet do you live on? ALL research shows the efficacy of behavior therapy for a host of psychiatric disorders. Will you please educate me about the empirical research showing that behavioral therapy causes brain damage? Please provide citations and links. Frankly, ALL research shows that psychiatric medications CAUSE a host of unwanted side effects, from sexual dysfunction, suicidal thoughts, TD, metabolic syndrome, and, of course NEURONAL LOSS. Does behavior therapy have these side-effects? Inquiring (and sane) minds want to know! Oh, and before you brand me as a Luddite or Scientologist, I fully understand that medications are necessary in the treatment of psychoses, schizophrenia, psychotic depression and bipolar I disorder. But these medications come with unwanted costs.

Federal prosecutors have issued a subpoena seeking information about the work and statements of three prominent Harvard researchers who have been the focus of a Congressional investigation into conflicts of interest in medicine.

The researchers — Drs. Joseph Biederman, Thomas Spencer and Timothy E. Wilens — are named in the subpoena, which was sent on Wednesday to Fletch Trammel, a lawyer who represents state attorneys general in lawsuits that claim makers of antipsychotic drugs defrauded state Medicaid programs by improperly marketing their medicines.

The three researchers have advocated increased use of antipsychotic medicines in children and have accepted lucrative consulting agreements from the drugs’ makers. Senator Charles E. Grassley, an Iowa Republican investigating conflicts of interest in medicine, found that each of the researchers had failed to report much of his consulting income to Harvard. Mr. Grassley has also said that Dr. Biederman and Dr. Wilens might have violated federal and university research rules. The controversy led Dr. Biederman to suspend his work with the drug industry.

The subpoena was issued by the Federal District Court for the Massachusetts District; it was sought by the United States attorney in Massachusetts, Michael J. Sullivan, and by the Health and Human Services Department inspector general, Daniel R. Levinson. The subpoena seeks all documents produced in litigation relating to the three researchers as well as transcripts of any depositions of them.

Mr. Trammel said he would “comply with the subpoena and facilitate the U.S. attorney’s investigation in any way I can.”

Peter Spivack, a lawyer for Dr. Biederman, and Mark Paoletta, a lawyer for Dr. Wilens and Dr. Spencer, said they were unaware of a subpoena.

A spokeswoman for Mr. Sullivan declined to comment on the investigation.

Hey all. I have posted another comment on this on my post on the subject at http://drbremer.blogspot.com

... If these guys indeed violated federal research rules in a meaningful way, then shame on them and my support immediately dissolves. MGH deserves better! And, I agree with the angry people here then -- children deserve better! However, so far I have not heard evidence to that effect. Biederman's big statements don't bug me at all as they show nothing except his big ego -- which is not a crime and seems pretty common in leaders of a variety of fields.

And, if these guys are simply being obliterated for their failure to report income to a University, I wonder why the same effort hasn't been put into those who run the country and fail to report income/pay taxes with the IRS. Not that it is right for anyone, but I again wonder about this as a politician's attack on individuals.

Tom Spencer is not mentioned in the research complaints. Unlike Biederman, he is a soft spoken, sweet doc who I was lucky enough to see interview child patients with care. He had nothing of Biederman's blustering way. Of course, I could have just seen him on a good day ... Maybe others who learned from him or had him as a treator could speak up?

Virtually all the psychiatrists who wrote the latest clinical guidelines for how to treat depression, bipolar disorder, and schizophrenia had financial ties to drug companies, according to preliminary findings by Boston-based researchers.

Their study is the first to examine potential conflicts of interest in the American Psychiatric Association panels that write the treatment guidelines widely used by practitioners, the paper's authors said.

The guidelines focus heavily on medications and give relatively little attention to nondrug treatments and how and when to phase out drugs prescribed for mentally ill patients, the authors wrote. They said three common diagnoses generate some $25 billion in drug sales per year.

"Most patients assume that when they're prescribed a drug, the decision is made on the basis of an objective review of the scientific evidence," said the paper's lead author, Lisa Cosgrove of the University of Massachusetts at Boston. "However, our study raises the question: Is that decision based in science, or is there a financial incentive behind it? This is an important question because the lack of biological tests for mental disorders renders psychiatry especially vulnerable to industry influence."

The psychiatric association re sponded that its guidelines, which sum up research and real-world experiences with treatments, go through a long and elaborate vetting process and that people who get significant portions of their income from drug companies are excluded from the guideline panels.

"We work very hard to ensure that the guidelines that we develop and publish are free of bias to the greatest possible extent," said Dr. John S. McIntyre, chairman of the guideline steering committee.

The study, scheduled to be published online this month in the journal Psychotherapy and Psychosomatics, found that among 20 authors of the guidelines, 18 had at least one financial tie to drug companies. It did not name names or specify sums, but found that 12 guideline authors had ties in at least three categories, such as consulting, research grants, speaking fees, or stock ownership.

To find financial ties, Cosgrove and her colleagues, who included Sheldon Krimsky of Tufts University and Dr. Harold Bursztajn of Harvard Medical School, searched publicly accessible databases such as Medline and the records of the federal patent office.

Dr. Roy Perlis, listed as a consultant on the bipolar guidelines, works in psychiatric genetics at Massachusetts General Hospital. In published papers - including one that examined financial conflicts of interest in clinical trials of psychiatric medications - he disclosed having received consultant or speaker's fees from five major drug companies: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmith Kline, and Pfizer.

But Perlis noted that the guidelines for bipolar disorder make two main points, neither of which benefit drug companies: that lithium, which has long been available as an inexpensive generic drug, is still the "gold-standard treatment" and "that certain kinds of talk therapy are a very important part of treatment."

"My job is to find better treatments for my patients. These are awful illnesses. People really suffer," he said. "And the people who are most responsible for developing new treatments right now are the pharmaceutical companies. What is being lost in all this is that if I didn't work with them, I couldn't do my job as a scientist - the part of my job that says we have people who are suffering that need new treatments."

The pharmaceutical industry defends its practice of paying "thought leaders" in various specialties to lend their expertise to drug development and marketing, saying that their input benefits both colleagues and patients and that they must be paid for their work.

But there is a growing backlash against conflicts of interest in medicine. A posse of those pushing for change in the medical culture is centered in Boston and includes Drs. Marcia Angell and Jerome Kassirer, former editors of the New England Journal of Medicine, and researchers such as Cosgrove and Krimsky. These critics contend that financial ties introduce the potential for bias, and at the very least, all such ties must be disclosed.

"What we're saying," said Krimsky, is that guideline writers "should be totally transparent about their relationships with the drug companies so people reading a guideline might ratchet up the skepticism they might have about the use of drugs as the first line of therapy."

This week in the Journal of the American Medical Association, a group of influential medical leaders went further, calling on medical specialty groups to adopt tough policies against industry influence, including appointing "only individuals who have no ties to industry" to committees writing treatment guidelines. Among the leaders, who specified they were not acting as representatives of their organizations, was the medical director and CEO of the psychiatric association.

The psychiatric association now requires guideline writers to publish any financial ties along with the guidelines they work on, but at the time the current guidelines for depression, bipolar disorder, and schizophrenia were published in 2004 and 2005, no such disclosures were required.

McIntyre, of the psychiatric association, said the steering committee that oversees the guideline-creation process has always screened proposed members of the groups that work on each set of guidelines for potentially troubling ties, including spouses who work for drug companies. The idea, he said, is to avoid people who get more than roughly 5 percent to 15 percent of their income from pharmaceutical firms, especially when from one particular company.

It would be a mistake to disqualify everyone with drug-company ties, he said, because it would mean losing valuable expertise in research that must be evaluated, but the association is considering whether to set a limit on committee members' industry income and research support.

The guidelines - the psychiatric association has produced 16 - also go out to hundreds of psychiatrists and others for comment and review, McIntyre said. "When you subject a document to that kind of review, by a large number of people, a single voice that might unwittingly be biased gets diluted," he said.

The new paper found that all of the authors of the schizophrenia and bipolar guidelines had relationships with the drug industry, and 60 percent of the authors on depression did. More than three-quarters received research funding from drug companies, and more than one-third served on the speakers' bureaus of drug companies.

In an editorial, this month's American Journal of Psychiatry singles out speakers' bureaus as the clearest example of conflict of interest, noting that they supply prominent psychiatrists "to deliver company-approved presentations that market their drugs to their clinical colleagues in the guise of medical education."

Sorry but I also cannot agree with your post re Prof Biederman. Having read a fair bit of his literature I think the best thing that can be said is that Biederman is a clever scientist who has built a tall ivory tower on the most superficial and narrow foundations of a blinkered medical model that has no place in child & adolescent psychiatry.

His paediatric bipolar hypothesis is deeply flawed and has caused harm to many children, teens and their families (even if they think not). He appears to totally discount or even be ignorant of the extensive and far more robust attachment and trauma research literature that has a far broader and deeper scientific foundation.

In fact the "broad (in terms of symptoms accepted as 'mania') phenotype pediatric bipolar" model he proposes is a thin tower of data built on nothing more than assumed criteria and is starting to topple in the c&a psychiatric literature. It never got far beyond the shores of the USA anyway.

His personal credentials are also severely tarnished if reports of his incredible "fury" and foul temper are to be believed. Indeed by basing bipolar in children on "irritability" alone and throwing hour long temper tantrums himself when a speaker's check is delayed - one has to wonder how much of his own projection (as an ego defence) colours his research.

Dr Carlat I find myself in almost total agreement with you on all other matters. If Pharma can influence us so pervasively, what about one's university culture in the halcion days of youth? Perhaps have a think about your post - how much is the influence of your "alma mater" colouring your analysis of Prof Biederman's work?

Anonymous asks:Gina,It could be true that some of the patients that Dr. Biederman was seeing were as sick as you describe, who got there after failing many other avenues. However, to extrapolate from these rare cases and recommend the "run-of-the-mill" psychiatrists (as you put it) that they should prescribe antipsychotics to hordes of children is not proper.-----------I'm sorry, Anonymous, but I never said such a thing.

And this is why internet-based "discourse" is so tedious and, no doubt, a waste of time. There is so much mind-reading, jumping to conclusions, and exaggerating to ridiculous extremes that there is LITTLE actual discourse and too much self-medicating thrashing about. Too much heat and scant light.

"With all DUE respect, behavioral therapy causes scaring and brain damage??? Really: What planet do you live on? ALL research shows the efficacy of behavior therapy for a host of psychiatric disorders. Will you please educate me about the empirical research showing that behavioral therapy causes brain damage?"

-----------Another example of why this kind of discourse is wasted time (and if I weren't sitting here waiting for a delayed flight, I wouldn't bother).

If you honestly want to pay "due respect," it's best to actually read a person's post. What you've done here is put my comment through a blender and poured it out. So, it seems you don't really want a response. But I do want to point out your error, lest someone read your post and assume it is an accurate recounting.

Repeat after me: It's not about the money; it's about the research, it's about the medication, and it's about "victimizing" children who are being "labeled" and treated for severe bi-polar disorder.

Remember: The heart, lungs, kidneys, etc. are ORGANS. The brain, well, it's just a vaporous mass where the "self" resides.

Some day, if the neuroscience luddites have their way, "talk therapy" will heal holes in a child's heart and cystic fibrosis. And if they can't provide studies to prove it, well, they will bully you into believing it.